UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
FUNDAMENTAL PATIENT ASSESSMENT TOOL
.
1 PATIENT INFORMATION

Student: Alexandra Bair

Assignment Date: 6/23/15
Agency: Bayfront Medical Center

Patient Initials: J.R.

Age: 69

Admission Date: 06/11/15

Gender: Female

Marital Status: Married

Primary Medical Diagnosis: S72.401A/S42.201A

Primary Language: English

Other Medical Diagnoses: N/A

Level of Education: Masters Degree in Education

Code Status: Full code

Occupation (if retired, what from?): Retired, high school English

teacher

Advanced Directives: Yes, living will

Number/ages children/siblings: 1 son, age 41

Surgery Date: 06/11/15 Procedure: Right distal femoral

placement, arthroplasty revision
Surgery Date: 06/15/15 Procedure: Left hemiarthroplasty
of the shoulder
Type of Insurance: Medicare

Served/Veteran: No
Living Arrangements: Lives with husband, 3 story house
with an elevator, main floor complete so she can stay on the
first floor
Culture/ Ethnicity /Nationality: Italian American
Religion: None

+1 CHIEF COMPLAINT: I was in Indiana visiting my son for my granddaughters kindergarten graduation
and I am not sure if I slipped or tripped but I feel and broke my leg and my shoulder (06/04/15). I as then flown
to Florida where my husband and I live and was operated on here in St. Petersburg at Bayfront (06/11/15).
+3 HISTORY OF PRESENT ILLNESS: Patient was visiting her 41 year old son in Indiana for
granddaughters kindergarten graduation when slipped/tripped and fell on 06/04/15 and fractured right leg and left
shoulder. Patients fractures diagnosed at local hospital in Indiana (patient could not remember the name). Patient was
transferred from Indiana to Bayfront Medical Center for management of fractures in the right femur and left shoulder.
Admitted to hospital on 06/11/15 and same day underwent right distal femoral placement, arthroplasty revision with
removal of all her components of the right knee arthroplasty, irrigation and debridement of the right knee bone and
tendon. On 06/15/15 was taken back to surgery for left hemiarthroplasty of the shoulder. Patient admitted to the rehab
floor on 06/18/15 at Bayfront Medical Center. The pain began when patient fell and broke her right femur and left
humerus on 06/04/15 described pain at a level 10/10. Patient reports sharp pain in her right knee at a level 8/10 when
moving the leg and moving from the bed to the wheelchair but pain has improved since the initial fracture because can
now put full weight on her right leg during physical therapy. Movement of the right leg causes patient more pain. Ice and
repositioning the leg help to alleviate the pain along with prescribed oxycodone (Oxycotin) 10MG, Q12H but pain only
alleviated to a 4 or 5 out of 10. Fractures were treated by two separate surgeries and patient is now working with physical
therapy to move leg and build strength by walking. Patient is also working with occupational therapy to work on

activities of daily living.

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease

Father

76

Unknown

Mother

76

Unknown

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

Gout

(Angina,
MI, DVT
etc.)
Heart
Trouble

Glaucoma

Diabetes

Cancer

Bleeds Easily

Management/Treatment
Surgery, pain medications and 4 months outpatient physical
therapy
Surgery outpatient, minimum walking and some pain meds
Lisinopril, exercise and diet
Pravastatin, diet, exercise
Diet and exercise
Levemir, Humalog, Januvia, exercise, diet

Asthma

Cause
of
Death
(if
applicable)

Arthritis

2
FAMILY
MEDICAL
HISTORY

Anemia

Cholecystectomy
Hypertension
Dyslipidemia
Obesity
Diabetes Mellitus
Environmental
Allergies

Unknown
Unknown
Unknown
Unknown
1992

Alcoholism

2009

Operation or Illness
Right total knee arthroplasty

Age (in years)

Date

Brother
Sister
relationship
relationship
relationship

Comments:
Mother and father both died at the age of 76 for unknown reasons. Father had hypertension, age unknown when acquired.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date unknown)
Adult Tetanus (Date unknown)
Influenza (flu) (08/2014)
Pneumococcal (pneumonia) (Date unknown)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS
Medications
Other (food, tape,
latex, dye, etc.)

NAME of
Causative Agent

YES

NO

Type of Reaction (describe explicitly)

No known allergies
None

University of South Florida College of Nursing Revision September 2014

 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Diabetes mellitus (DM) is characterized by high blood glucose or too much sugar in the body. It can result from a defect of insulin
secretion or insulin activation or sometimes, both a defect in secretion and activation. 8.3% of the population in the United States has
been diagnosed with diabetes and it is the 7th cause of death in the United States. There are four types of DM: type 1, type 2, other
specific types, and gestational diabetes. Type 1 and type 2 DM are the more common of the four, with approximately 5-10% of the
cases being type 1 and approximately 90-95% being type 2 (Huether, McCance, 2012, Pg 459). Diabetes mellitus is diagnosed by any
of the following levels: HbA1C levels, fasting plasma glucose (FPG) levels, 2-hour plasma glucose levels during oral glucose tolerance
testing or random glucose levels in an individual with symptoms. HbA1C is a glycosylated hemoglobin, which is the permanent
attachment of glucose to hemoglobin and reflects the glucose exposure over the life of a red blood cell (RBC). It gives a better
understand because it shows the glucose levels over time versus a snapshot (Huether, McCance, 2012, Pg 459).
Type 2 DM is when the body is resistant to insulin and does not secrete enough insulin. Non-insulin-dependent diabetes mellitus is
significantly more common in frequency than type 1 and has been rising in incidence since 1940. Occurrence varies by ethnic group
and gender but highest occurrence is in black women (Huether, McCance, 2012, Pg 462). There appears to be a connection between
genetic and environmental interactions and type 2 DM. Widely recognized risk factors are obesity, age, hypertension, physical
inactivity, and family history. Something known as the metabolic syndrome which is a combination of disorders including central
obesity, dyslipidemia, prehypertension, and elevated fasting blood glucose level, makes it much more likely to develop type 2 DM.
A few genes have been linked to type 2 DM including the ability to sense blood glucose levels, insulin synthesis and insulin secretion.
Beta-cells are the main cells involved with DM because they secrete insulin. Other genes involved in diabetes mellitus are proinsulin
and insulin molecular structures, insulin receptors, hepatic synthesis of glucose, glucagon synthesis, and cellular responsiveness to
insulin stimulation (Huether, McCance, 2012, Pg 462). A combination of the previously listed genetic abnormalities with
environmental influences result in the mechanism of type 2 diabetes mellitus. Insulin resistance is associated with obesity through 4
different mechanisms (Huether, McCance, 2012, Pg 462). The first mechanism is adipokines which are hormones produced in the
adipose tissue. Changes in the hormones are associated with inflammation and decreased insulin sensitivity. Also, Intracellular
deposits of triglycerides and cholesterol interfere with intracellular insulin signaling and decreases tissue sensitivity in response to
insulin (Huether, McCance, 2012, Pg 463). Another mechanism is when inflammatory cytokines are released from adipocytes. The
inflammatory cytokines cause insulin resistance and are cytotoxic to beta cells. The last mechanism where obesity contributes to the
development of insulin resistance and diabetes is hyperinsulinemia which is correlated with obesity and diminishes the insulin
receptor density. An increase in glucagon concentration occurs in type 2 DM because alpha cells of the pancreas become less reactive
to glucose inhibition which in turn results in an increase of glucagon secretion (Huether, McCance, 2012, Pg 463). High levels of
glucagon thus increase blood glucose by triggering the breakdown of glycogen and the generation of glucose from non-carbohydrate
carbon substrates. Another factor in insulin resistance is when hormones like incretins are released from the GI tract in response to
food and boost beta cell sensitivity to glucose. This helps to improve the reactions of insulin to meals.
Clinical manifestations of type 2 DM range are unclear because they range from children and adolescents to adults. It generally
affects people who are overweight, have dyslipidemia, hyperinsulinemia, and hypertension. Symptoms of type 2 DM include
polyuria, polydipsia, fatigue, pruritus, recurrent infections, visual changes or symptoms of neuropathy. If the DM is not treated then
another complications such as coronary artery, peripheral artery and cerebrovascular disease may develop (Huether, McCance, 2012,
Pg 463).
The treatment goal of people with type 2 diabetes mellitus is a normal blood glucose level. Recommended prevention and treatments
include exercise interventions and dietary measures for weight loss. Decreasing the obesity by weight loss results in reduced insulin
resistance and improved glucose tolerance. The main approach for treatment is through appropriate dieting and exercise but some
medications are needed to help with management. Oral hypoglycemic agents such as insulin therapy may be needed due to loss of
beta-cell function. Loss of beta-cell function progresses over time (Huether, McCance, 2012, Pg 463).

5 MEDICATIONS:
Name: bisacodyl (Dulcolax)

Concentration:

Route: PR

Dosage Amount: 10mg

Frequency: Daily

Pharmaceutical class: stimulant laxatives

Home

Hospital X

or

Both

Indication: Treatment for constipation

Adverse/ Side effects: abdominal cramps, nausea, diarrhea, rectal burning, hypokalemia, muscle weakness, protein-losing enteropathy, tetany
Nursing considerations/ Patient Teaching: advise patients, that laxatives should be used for short-term therapy, prolonged therapy may cause electrolyte
imbalance and dependence, advise patient to increase fluid intake to at least 1500-2000mL/day, patients with cardiac disease to avoid straining during bowel
movements, bisacodyl should not be used when constipation is accompanied by abdominal pain, fever, nausea, or vomiting

University of South Florida College of Nursing Revision September 2014

Name: docusate-senna (Senokot S)

Concentration:

Route: PO

Dosage Amount: 1 tab

Frequency: BID

Pharmaceutical class: stimulant laxatives, stool softeners

Home

Hospital X

or

Both

Indication: Treatment of constipation associated with dry, hard stools and decreased intestinal motility, prevention of opioid-induced constipation
Adverse/ Side effects: electrolyte imbalances, dehydration, abdominal cramps, nausea, vomiting, diarrhea, rashes, urine discoloration
Nursing considerations/ Patient Teaching: Advise patients that laxatives should be used only for short-term therapy. Long-term therapy may cause electrolyte
imbalance and dependence. Instruct patients with cardiac disease to avoid straining during bowel movements, advise patient not to use laxatives when
abdominal pain, nausea, vomiting, or fever is present.
Name: enoxaparin (Lovenox)

Concentration: 40mg/0.4mL

Route: SQ

Dosage Amount: 40mg

Frequency: Daily

Pharmaceutical class: antithrombotics, low molecular weight heparins Home

Hospital

or

Both

Indication: prevent venous thromboembolism (VTE) and/or pulmonary embolism (PE), in surgical or medical patients
Adverse/ Side effects: dizziness, headache, insomnia, edema, constipation, increase liver enzymes, nausea vomiting, urinary retention, alopecia, ecchymoses,
pruritus, rash, urticaria, hyperkalemia, bleeding , anemia, eosinophilia, thrombocytopenia, erythema at injection site, hematoma, irritation, pain, osteoporosis,
fever
Nursing considerations/ Patient Teaching: assess for signs of bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, black, tarry stools,
hematuria, fall in hematocrit or BP, do not confuse Lovenox with Levemir, cannot be used interchangeably with unfractionated heparin or other low-molecularweight heparins, administer deep into subcutaneous tissue, alternate injection sites, advise patient to report any symptoms of unusual bleeding or bruising,
dizziness, itching, rash, fever, swelling, or difficulty breathing to health care professional. Instruct patient not to take aspiring, naproxen, or ibuprofen without
consulting health care provider
Name: insulin detemir (Levemir)

Concentration: 12units/0.12mL

Route: SQ

Dosage Amount: 12 units

Frequency: Q12hr

Pharmaceutical class: pancreatics

Home

Hospital

or

Both

Indication: control of hyperglycemia in patients with type 1 (IDDM) and type 2 (NIDDM) diabetes mellitus
Adverse/ Side effects: hypoglycemia, lipodystrophy, pruritis, erythema, swelling, allergic reactions including anaphylaxis
Nursing considerations/ Patient Teaching: High Alert- insulin related medication errors have resulted in patient harm and death. Clarify ambiguous orders,
check type, dose, and expiration date with another licensed nurse. Do not interchange insulins without consulting physician, do not confuse Levemir (insulin
detemir) with Lovenox (enoxaparin), do not mix insulin detemir with any other insulin or solution, rotate injection sites, not for IV administration or use with
insulin pump, instruct patient on proper technique for administration, include type of insulin, equipment, storage, and place to discard syringes, explain to
patient that this medication controls hyperglycemia but does not cure diabetes, therapy is long term, instruct patient in proper testing of serum glucose and
ketones, emphasize the importance of compliance with nutritional guidelines and regular exercise, instruct patient to notify health care provider of all Rx and
OTC medications, vitamins or herbal products being taken, advise patient to notify health care provider if nausea, vomiting or fever develops, instruct patient
on signs and symptoms of hypoglycemia and hyperglycemia, patients with DM should carry a source of sugar and ID describing their disease.
Name: Lisinopril

Concentration:

Route: PO

Dosage Amount: 5mg

Frequency: Daily

Pharmaceutical class: Ace Inhibitors

Home

Hospital

or

Both X

Indication: Alone or with other agents in the management of hypertension

Adverse/ Side effects: Dizziness, fatigue, headache, weakness, cough, hypotension, chest pain, abdominal pain, diarrhea, nausea, vomiting, erectile dysfunction,
impaired renal function, rashes, hyperkalemia, angioedema
Nursing considerations/ Patient Teaching: Monitor BP and pulse frequent during initial dose adjustment and periodically during therapy. Assess patient for
signs of angioedema, monitor frequency of prescription refills to determine compliance, monitor renal function. May cause increase in BUN, and serum
creatinine. Instruct patient to take medication as directed at the same time daily, take missed doses as soon as remembered but not if almost time for the next
dose. Caution patient to avoid salt substitutes that contain potassium or foods containing high levels of potassium or sodium. Caution patient to change positions
slowly to minimize orthostatic hypotension. Instruct patient to notify health care professionals if rash, mouth sores, sore throat, fever, swelling of hands or feet,
irregular heartbeat, chest pain, dry cough, hoarseness, swelling of face, eyes, lips or tongue, or difficulty swallowing or breathing. Encourage patient to comply
with additional interventions for hypertension (Weight reduction, low sodium diet, discontinuation of smoking, moderation of alcohol consumption, regular
exercise and stress management)

Name: insulin lispro

Concentration: sliding scale

Dosage Amount: sliding scale

University of South Florida College of Nursing Revision September 2014

Route: SQ

Frequency: ACHS

Pharmaceutical class: pancreatics

Home

Hospital

or

Both X

Indication: Control of hyperglycemia in patients with type 1 and type 2 diabetes mellitus
Adverse/ Side effects: hypoglycemia, lipidystrophy, pruritus, erythema, swelling, allergic reactions including anaphylaxis
Nursing considerations/ Patient Teaching: Monitor blood pressure before administration, Assess for symptoms of hypoglycemia and hyperglycemia periodically
during therapy, monitor body weight periodically, monitor glucose every 6 hours during therapy. Overdose is manifested by symptoms of hypoglycemia.
Clarify all ambiguous orders, check type, dose, and expiration date, must be used with longer acting insulin, administer insulin lispro within 15 minutes before a
meal, rotate injection sites, instruct patient on proper technique for administration, therapy is long term, instruct patient in proper testing of serum glucose and
ketones, emphasize importance of compliance with nutritional guidelines and regular exercise, instruct patient on signs and symptoms of hypoglycemia and
hyperglycemia and what to do if they occur.
Name: nicotine (Nicotine Transdermal Patch-24 hour)

Concentration:

Route: TD

Dosage Amount: 14mg

Frequency: Daily

Pharmaceutical class:

Home

Hospital X

or

Both

Indication: Adjunct therapy (with behavior modification) in the management of nicotine withdrawal in patients desiring to give up cigarette smoking.
Adverse/ Side effects: Headache, insomnia, abnormal dreams, dizziness, drowsiness, impaired concentration, nervousness, weakness, burning at patch site,
erythema, pruritus, cutaneous hypersensitivity, rash, sweating, tachycardia, chest pain, hypertension, abdominal pain, abnormal taste, constipation, diarrhea,
dry mouth, dyspepsia, hiccups, nausea, vomiting, paresthesia
Nursing considerations/ Patient Teaching: Prior to therapy assess smoking therapy. Assess patient for symptoms of smoking withdrawal periodically during
nicotine replacement therapy. Monitor for nausea, vomiting, diarrhea, increased salivation, abdominal pain, headache, dizziness, auditory and visual
disturbances, weakness, dyspnea, hypotension and irregular pulse. Patch can be worn 16 or 24 hours, patch can be removed before patient goes to bed,
encourage patient to participate in a smoking cessation program while using this production. Instruct patient in application and use of patch, apply patch at the
same time each day, apply to clean dry skin of upper arm or torso, wash hands with soap and water after handling patches, do not trim or cut patch, no more
than one patch should be worn at a time, alternate application sites, may cause drowsiness or dizziness.
Name: nystatin topical

Concentration:

Route: Topical

Dosage Amount: 100,00 units/g

Frequency: TID

Pharmaceutical class: Antifungal

Home

Hospital X or

Both

Indication: Treatment of a variety of cutaneous fungal infections, including cutaneous candidiasis, tinea pedis, tinea cruris, tinea corporis, tinea versicolor.
Adverse/ Side effects: Burning, itching, local hypersensitivity reactions, redness, stinging
Nursing considerations/ Patient Teaching: Inspect involved areas of skin and mucous membranes before and frequently during therapy. Increased skin
irritation may indicate need to discontinue medication. Apply small amount to cover affected area completely. Avoid the use of occlusive wrappings or dressings
unless directed by health care professional. Instruct patient to apply medication as directed for full course of therapy, even if feeling better. Emphasize the
importance of avoiding the eyes. Advise patient to report increased skin irritation or lack of response to therapy to health care professional.
Name: oxycodone (Oxycotin)

Concentration:

Route: PO

Dosage Amount: 10mg

Frequency: Q12hr

Pharmaceutical class: Opioid agonists

Home

Hospital X

or

Both

Indication: Moderate to severe pain; extended release product should be used for patients requiring around-the-clock management of chronic pain.
Adverse/ Side effects: Confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred vision, miosis,
respiratory depression, orthostatic hypertension, constipation, dry mouth, choking, GI obstruction, nausea, vomiting, urinary retention, flushing, sweating,
physical dependence, psychological dependence, tolerance.
Nursing considerations/ Patient Teaching: Assess type, location, and intensity of pain prior to and 1 hr (peak) after administration. Patients taking controlledrelease tablets may also be given supplemental short-acting opioid doses for breakthrough pain. Assess BP, pulse, and respirations before and periodically
during administration. If respiratory rate is less than 10 per minute, assess level of sedation. Prolonged use may lead to physical and psychological dependence
and tolerance. Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk, and laxatives to
minimize constipating effects. Accidental overdose of opioid analgesics has resulted in fatalities. Before administering, clarify all ambiguous orders; have second
practitioner independently check original order and dose calculations. Do not confuse short-acting oxycodone with long-acting Oxycontin. Do not confuse
oxycodone with hydrocodone. Do not confuse Oxycontin with MS Contin. Explain therapeutic value of medication prior administration to enhance the analgesic
effect. May be administered with food or milk to minimize GI irritation. Instruct patient on how and when to ask for and take pain medication. Advise patient
that oxycodone is a drug with known abuse potential. Medication may cause drowsiness or dizziness. Advise patient to call for assistance when ambulating or
smoking. Caution patient to avoid driving and other activities requiring alertness until response to medication is known. Advise patient to make position
changes slowly to minimize orthostatic hypotension. Advise patient to avoid concurrent use of alcohol or other CNS depressants with this medication. Encourage
patient to turn, cough and breathe deeply every 2 hr to prevent of atelectasis.

Name: pravastatin
Route: PO

Concentration:

Dosage Amount: 40mg

Frequency: Daily

University of South Florida College of Nursing Revision September 2014

Pharmaceutical class: hmg coa reductase inhibitors (statin)

Home

Hospital

or

Both X

Indication: Adjunctive management of primary hypercholesterolemia and mixed dyslipidemias. Primary prevention of coronary heart disease in asymptomatic
patients with increased total and low-density lipoprotein (LDL) cholesterol, and decreased high-density lipoprotein (HDL) cholesterol. Secondary prevention of
myocardial infarction, coronary revascularization, stroke and overall mortality in patients with clinically evident coronary heart disease.
Adverse/ Side effects: Amnesia, confusion, dizziness, headache, insomnia, memory loss, weakness, rhinitis, bronchitis, chest pain, peripheral edema, abdominal
cramps, constipation, diarrhea, flatus, heartburn, altered taste, drug-induced hepatitis, dyspepsia, increased liver enzymes, nausea, pancreatitis, erectile
dysfunction, rash pruritus, hyperglycemia, rhabdomyolysis, arthralgia, arthritis, immune-mediated necrotizing myopathy, myalgia, myositis, hypersensitivity
reactions.
Nursing considerations/ Patient Teaching: Obtain a diet history, especially with regard to fat consumption. Instruct patient to take medication as directed, not to
skip doses or double up on missed doses. Advise patient to avoid grapefruit juice during therapy. Advise patient that this medication should be used in
conjunction with diet restrictions, exercise and cessation of smoking. Instruct patient to notify health care professional if unexplained muscle pain, tenderness or
weakness occurs, especially if accompanied by fever or malaise. Advise patient to wear sunscreen and protective clothing to prevent photosensitivity reactions.
Advise patient to notify health care professional of medication regimen prior to treatment or surgery. Emphasize the importance of follow-up exams to
determine effectiveness and to monitor for side effects.
Name: sitagliptin (Januvia)

Concentration:

Route: PO

Dosage Amount: 50mg

Frequency: Daily

Pharmaceutical class: Enzyme Inhibitors

Home

Hospital

or

Both X

Indication: adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes mellitus; may be used as monotherapy or combination
therapy with metformin, a thiazolidinedione, a sulfonylurea, or insulin.
Adverse/ Side effects: Headache, pancreatitis, nausea, diarrhea, acute renal failure, upper respiratory tract infection, nasopharyngitis, arthralgia, back pain,
myalgia, allergic reactions including ANAPHYLAXIS, ANGIOEDEMA, EXFOLIATIVE SKIN CONDITIONS (Stevens-Johnson Syndrome,) rash, urticaria,
Nursing considerations/ Patient Teaching: Observe patient for signs and symptoms of hypoglycemic reactions. Monitor for signs of pancreatitis during therapy.
If pancreatitis occurs, discontinue sitagliptin and monitor serum and urine amylase, amylase/creatinine clearance ratio, electrolytes, serum calcium, glucose and
lipase. Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome. Discontinue therapy if severe or if accompanied with fever, general
malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis, and/or eosinophilia.
Instruct patient to take sitagliptin as directed. Take missed doses as soon as remembered, unless it is almost time for next dose; do not double doses. Explain to
patient that sitagliptin helps control hyperglycemia but does not cure diabetes. Therapy is usually long term. Encourage patient to follow prescribed diet,
medication, and exercise regimen to prevent hyperglycemic or hypoglycemic episodes. Review signs of hypoglycemia and hyperglycemia with patient. Instruct
patient in proper testing of blood glucose and urine ketones. Advise patient to stop taking sitagliptin and notify health care professional promptly if symptoms of
hypersensitivity reactions or pancreatitis occurs.
Name: acetaminophen (Tylenol)

Concentration:

Route: PO

Dosage Amount: 500mg

Frequency: Q4hr, PRN

Pharmaceutical class: Antipyretic, Nonopioid analgesic

Home

Hospital X

or

Both

Indication: Treatment of: Mild pain, fever

Adverse/ Side effects: Increased liver enzymes, renal failure, neutropenia, pancytopenia, ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS,
STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, rash, urticaria
Nursing considerations/ Patient Teaching: Assess overall health status and alcohol usage before administering acetaminophen. Patients who are malnourished or
chronically abuse alcohol are at higher risk of developing hepatotoxicity with chronic use of usual doses of this drug.
Assess amount, frequency, and type of drugs taken in patients self-medicating, especially with OTC drugs. Prolonged use of acetaminophen increases the risk of
adverse renal effects. For short-term use, combined doses of acetaminophen and salicylates should not exceed the recommended dose of either drug given alone.
Do not exceed maximum daily dose of acetaminophen when considering all routes of administration and all combination products containing acetaminophen.
Pain: Assess type, location, and intensity prior to and 3060 min following administration.
Fever: Assess fever; note presence of associated signs (diaphoresis, tachycardia, and malaise)
Advise patient to take medication exactly as directed and not to take more than the recommended amount. Chronic excessive use of greater than 4 grams a day
(2 g in alcoholics) may lead to hepatotoxicity, renal or cardiac damage. Adults should not take acetaminophen longer than 10 days unless directed by a health
care professional. Advise patient to avoid alcohol (3 or more glasses per day increase the risk of liver damage) if taking more than an occasional 1-2 doses.
Advise patient to discontinue acetaminophen and notify health care professional if rash occurs. Inform patients with diabetes that acetaminophen may alter
results of blood glucose monitoring. Caution patient to check labels on all OTC products. Advise patients to avoid taking more than one product containing
acetaminophen at a time to prevent toxicity.

Name: albuterol-ipratropium

Concentration: 3mL

Route: NEB

Dosage Amount: 3mL

Frequency: rQ4, PRN

Pharmaceutical class: adrenergic

Home

Hospital X

or

Both

University of South Florida College of Nursing Revision September 2014

Indication: Used as a bronchodilator to control and prevent reversible airway obstruction caused by asthma and COPD. Inhale: Used as a quick relief agent for
acute bronchospasm and for prevention of exercise induced bronchospasm. PO: Used as a long-term control agent in patients with chronic/persistent
bronchospasm.
Adverse/ Side effects: Nervousness, restlessness, tremor, headache, insomnia, PARADOXICAL BRONCHOSPASM (EXCESSIVE USE OF INHALERS) Chest
pain, palpitations, angina, arrhythmias, hypertension, nausea, vomiting, hyperglycemia, hypokalemia, tremor
Nursing considerations/ Patient Teaching: Assess lungs sounds, pulse and BP before administration and during peak of medication. Note amount, color, and
character of sputum produced. Monitor pulmonary function tests before initiating therapy and periodically during therapy. Observe for paradoxical
bronchospasm (wheezing). If condition occurs, withhold medication and notify healthcare professional immediately. Instruct patient to take albuterol as
directed. If on a scheduled dosing regimen, take missed dose as soon as remembered, spacing remaining doses at regular intervals. Do not double doses or
increase the dose or frequency of doses. Caution patient to not exceed recommended dose; may cause adverse effects, paradoxical bronchospasm or loss of
effectiveness of medication. Instruct patient to contact health care professional immediately if shortness of breath is not relieved by medication or is
accompanied by diaphoresis, dizziness, palpitations, or chest pain. Instruct patient notify health care professional if there is no response to the usual dose or if
contents of one canister are used in less than 2 wk. Asthma and treatment regimen should be re-evaluated and corticosteroids should be considered. Need for
increased use to treat symptoms indicates decrease in asthma control and need to reevaluate patients therapy.

5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
2000 ADA Diabetic diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Diabetic diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: A piece of ham and a fried egg, cup of regular
black coffee

Lunch: A Chicken wrap (sandwich), glass of water to drink

As the graph shows, the patient is eating the correct amount

of vegetables and proteins. The patient needs to increase
whole fruit intake and eat more dairy products. Increase in
dairy products have been known to decrease the incidence
of type 2 diabetes. For snacks or side, patient should have
more fruits or vegetables and maybe a yogurt as a snack
instead of the cookies. Other suggestions are to eat more
whole grains versus refined grains and to eat less sodium
due to the high cholesterol (dyslipidemia). The patient had
526 empty calories which is over the limit of 258. This
most empty calories per item occurred with the wrap the
patient has for lunch. Possibly another type of sandwich or
item for lunch would decrease the empty calories and fulfill
areas where the patient is lacking nutrition.

Dinner: lb. of ground beef with 1 cup tomato sauce and

brown rice, 1 cup of black beans, and 1cup of mixed
vegetables, glass of water
Snacks: Cookies (2) and a glass of milk at night
Liquids (include alcohol): coffee, water, water, milk

University of South Florida College of Nursing Revision September 2014

Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
When the patient is ill, the patient takes care of herself mostly but if need be, her husband can take of her.
How do you generally cope with stress? Or What do you do when you are upset?
When the patient is stressed, she calls a friend to vent. Patient claims to be even-tempered and does not get upset much.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient is currently feeling the most difficult time in her life. She feels she has so much to overcome with her fractures
and most daily tasks feel daunting. Denies feeling depression but definitely feels some anxiety and sense of being
overwhelmed.
+2 DOMESTIC VIOLENCE ASSESSMENT
Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? ___NO__________________________________________________
Have you ever been talked down to? ____ NO _____ Have you ever been hit punched or slapped? ___ NO ________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
____________ NO __________________________ If yes, have you sought help for this? ______________________
Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Intimacy vs. Isolation

Autonomy vs. Doubt & Shame

Initiative vs. Guilt
Industry
Generativity vs. Self absorption/Stagnation
Ego Integrity vs.

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:

The patient is 69 years old and in the Erikson stage of psychosocial development ego integrity versus despair. During this
stage, an older adult begins to look back on their life with a sense of accomplishment or failure. It is the acceptance of
ones life, worth and death. Ego integrity reflects the persons life was successful and they feel they accomplished what
was needed without regrets. The person in ego integrity is happy and reflects on their life with positive light, giving
advice to others. The other side of this stage is despair, a sense of dissatisfaction with life. Despair is when a person
believes they failed and have resentment and bitterness. Fear of death is usually seen in despair.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patient is in the ego integrity stage because she reflected on her life with happiness. She is a retired high school
English teacher and she enjoyed her job very much. She just celebrated 45 years happily married to her husband a few

University of South Florida College of Nursing Revision September 2014

days prior. She has a son in Indiana, whom she and her husband were visiting when she had the accident. Her son has a
daughter that just graduated from kindergarten. She also has 3 dogs that she loves. The dogs are all still up in Indiana
with her son because she cannot take care of them, currently. The patient is still active in the community prior to the
accident and travels with her husband in their RV.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The fall the patient had has impacted her life in the way where she cannot be independent cur rently. She is having trouble
with her positivity and happiness because she knows there is a lot of pain, recuperation and work to get back to what she

used to be able to do. She does not know if she even can get back to where she used to be.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
The patient believes the fall was the cause of her illness, though she does not know whether she slipped or tripped.
What does your illness mean to you?
The patient claims her illness means a lot of pain and a lot of work to recuperate and get back to before the accident. She
wonders if she even can get back to what it was like before the fall.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?_____Yes____________________________________________________________
Do you prefer women, men or both genders? ____Men_____________________________________________________
Are you aware of ever having a sexually transmitted infection? ___No_________________________________________
Have you or a partner ever had an abnormal pap smear? __No______________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? __No______________________________________
Are you currently sexually active? _____No____________________ If yes, are you in a monogamous relationship?
____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _______Birth control________________________
How long have you been with your current partner? __45 years_______________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? ___No______________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?
Patient claims that religion or spirituality has a moderate importance in her life. She believes she is a good person. She believes there
is a higher power and believes in Heaven.
____________________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
Patients religious beliefs do not influence her current condition.
____________________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)
Cigarettes
2 packs a day

Yes X No
For how many years? 55 years
(age 15

thru 69 )

University of South Florida College of Nursing Revision September 2014

If applicable, when did the

patient quit? 06/11/15

Pack Years: 110

Does anyone in the patients household smoke tobacco? If
so, what, and how much?

Has the patient ever tried to quit? Currently trying to quit

If yes, what did they use to try to quit? Nicotine
transdermal patch

Cigarettes and 1 pack per day

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What?
How much?
Volume:
Frequency:
If applicable, when did the patient quit?

Yes

No X
For how many years?
(age

thru

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No X
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No
5. For Veterans: Have you had any kind of service related exposure?
N/A

10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health?
Patient is a 69 year old, overweight patient. She is dressed appropriately for the season and appears to be well-nourished. Patient is
currently lying in bed since she recently had knee surgery and arm surgery. The patient has trouble ambulating and needs assistance.
Patient claims she was overall pretty healthy prior to the fall.

Integumentary: Patient has changes in appearance of skin by means of thinning and discolorations, incision on
right knee and left shoulder, right knee mostly healed, no signs of drainage or infection and left shoulder
containing staples where the incision was made, scab healing incision area, no sign of drainage or infection.
The patient denies problems with nails, dandruff, psoriasis, hives or rashes, or skin infections. The patient does
not use sunscreen. The patient showers every day in the morning.
HEENT: The patient has difficulty seeing and has glasses she wears at all times to see. Patient has cataracts that
she needs removed. Patient has dental problems and is losing teeth due to old age. Patient brushes teeth twice a
day, once in the morning and once at night. Patient visits the dentist every 6 months and has regular vision
screenings. Patient denies difficulty hearing, ear infections, sinus pain or infections, nose bleeds, post-nasal
drip, oral/pharyngeal infection.
Pulmonary: Patient is having difficulty breathing due to pain. Patients last chest X-ray was on June 18th 2015
and showed slight right diaphragmatic eventration and clear lungs with no pleural effusion. Patient denies
cough, asthma, bronchitis, emphysema, pneumonia, tuberculosis, environmental allergies.
Cardiovascular: Patient has history of hypertension (is taking medication to treat condition), hyperlipidemia, the
last EKG screening was this month (date unknown). Patient denies chest pain, angina, myocardial infarction,
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10

coronary artery disease, peripheral vascular disease, congestive heart failure, murmur, thrombus, rheumatic
fever, myocarditis, arrhythmias.
GI: Patient has diarrhea from suppositories given previously for constipation, patients last colonoscopy was this
year (date unknown). Patient denies gastroesophageal reflux disease, indigestion, hemorrhoids, yellow jaundice,
pancreatitis, colitis, diverticulitis, appendicitis, abdominal abscess, irritable bowel, cholecystitis, gastritis, ulcers,
blood in stool, and hepatitis.
GU: Patient denies nocturia, dysuria, hematuria, polyuria, kidney stones, bladder and kidney infection. Patient
has foley catheter (30 ml per hr)
Women Only: Patient has had PAP and pelvic exam once per year, date of last gynecological exam was this year
(date unknown). Patient menarche at age 13, menopause age 60, date of last mammogram was this year (date
unknown) and results were normal. Date of DEXA bone density was this year (date unknown) and results were
normal. Patient denies infection of the female genitalia, monthly self breast exam, and menstrual cycle.
Musculoskeletal: Patient has fractures in her right femur, and left humerus, weakness and pain in extremities
from fractures, and arthritis. Patient denies gout, and osteomyelitis.
Immunologic: Patient states having night sweats and fever from menopause. Patient denies chills with severe
shaking, HIV/AIDS, lupus, rheumatoid arthritis, sarcoidosis, tumor, life-threatening allergic reaction, and
enlarged lymph nodes.
Hematologic/Oncologic: Patient denies anemia, bleeding easily, bruising easily, cancer or blood transfusions.
Blood type is A+.
Metabolic/Endocrine: Patient has Type 2 Diabetes mellitus, and is taking insulin. Patient denies hypothyroidism,
hyperthyroidism, intolerance to hot/cold, and osteoporosis.
Central Nervous System: Patient denies cerebrovascular accident (stroke), dizziness, severe headaches,
migraines, seizures, ticks or tremors, encephalitis or meningitis.
Mental Illness: Patient denies depression, schizophrenia, anxiety or bipolar.
Childhood Diseases: Patient had measles, mumps and chicken pox as a child. Patient denies having polio or
scarlet fever.
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No.
Any other questions or comments that your patient would like you to know?
My last knee replacement took 15 weeks to heal. I am anxious to see how long it takes to get well.

10 PHYSICAL EXAMINATION:
General survey: Patient is a 69 year old female who is well-kept and overweight, with no visible signs of distress and is alert
and oriented AAO x3.
Height: 53 (63 inches) Weight: 123 kg BMI: 47.93 Pain (include rating and location): 8 in right knee
Pulse: 87 Blood Pressure (include location): 104/67 (left leg) Temperature (route taken): 98.7 (oral)
Respirations: 20 SpO2: 95% Room Air or O2: Room Air
Overall Appearance: Patient has clean and combed hair, is dressed appropriate for the season, and maintains eye contact
with no obvious handicaps. Patient is lying in bed due to fractures in her right femur and left shoulder.
Overall Behavior: Patient is awake, calm, relaxed and interacts well with others. Patients judgment is intact seen through
conversation.
Speech: Patient has clear, crisp dictation.
Mood and Affect: Patient appears depressed, but pleasant and cooperative.
Integumentary: Skin is warm, dry and intact except for incision sites at right knee and left shoulder. Skin turgor is elastic,
showing no dehydration. Skin shows no rashes, lesions or deformities. Nails are without clubbing and capillary refill is less
than three seconds except the right leg has edema, and the capillary refill is greater than 3 seconds. Hair is evenly distributed
on head, clean and without vermin.
IV Access: No IV present. Central access device is a single lumen PICC located in the right upper arm. Date of insertion is

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11

6/12/15. No fluids infusing.

HEENT: Facial features are symmetrical, no pain in sinus region or clicking of TMJ, Trachea midline, thyroid not enlarged
and no palpable lymph nodes. Sclera is white, and conjunctiva is clear without discharge. Eyebrows, eyelids, orbital areas,
eyelashes, and lacrimal glands are all symmetrical without edema or tenderness. Pupils are equal, round and reactive to light
and accommodation. Pupil size left and right 2mm. Peripheral vision intact and extraocular muscles intact through 6 cardinal
fields without nystagmus, ears symmetrical without lesions or discharge. Whisper test heard 12 inches from right and left
ears, nose without lesions or discharge. Lips, buccal mucosa, floor of mouth, and tongue pink and moist without lesions.
Pulmonary/Thorax: Respirations are regular and unlabored, transverse to anterioposterior ratio 2:1, chest expansion
symmetric and percussion resonant throughout all lung fields and dull towards posterior bases. No sputum production. Lung
sounds clear in right upper lobe, right middle lobe, right lower lobe, left upper lobe, and left lower lobe.
Cardiovascular: Patient has no lifts, heaves or thrills and heart sounds (S1 and S2) audible, regular, and without murmurs,
clicks, or adventitious heart sounds. PMI felt at the 5th intercostal space, midclavicular line. No jugular vein distention, and
pulses bilaterally equal, except in right leg due to edema. Apical pulse +3, carotid +3, brachial +3, radial +3, femoral +3 in
the left, and +2 in the right, popliteal +3 in the left, +1 in the right, dorsalis pedis +3 in the left, +1 in the right, posterior tibial
+3 in the left, +1 in the right. No temporal or carotid bruits. Edema +2 in right leg with pitting, all other extremities warm
with capillary refill less than 3 seconds. Right leg capillary refill greater than 3 seconds.
GI: Patient has active bowel sounds in all four quadrants and no bruits auscultated. No organomegaly present and percussion
is dull over liver and spleen and tympanic over stomach and intestines. Abdomen non-tender to palpation and last bowel
movement soft, liquid medium brown and recorded on 6/20/15. Genitalia not assessed because patient alert, oriented and
denies problem.
GU: Patients urine is clear, and the foley catheter previous 24 hr output (N/A), costovertebral angle punch without rebound
tenderness.
Musculoskeletal: Patient does not have full range of motion in all extremities. Strength in right upper extremity is a 5
against full resistance. The left upper extremity had no range of motion due to healing from surgery and providers
instructions not to move it. Strength in the right lower extremity is a 3 against gravity but not against resistance and the
strength in the left lower extremity is a 5 against full resistance. The vertebral column looked to by without kyphosis or
scoliosis but patient was lying in bed. Neurovascular status intact with peripheral pulses palpable, no pallor, paralysis or
parathesias. Patients right leg and left should have limited ROM due to recent knee and shoulder surgery.
Neurological: Patient is awake, alert, oriented to person, place, time, and date. Cranial nerves 2-12 grossly intact and
sensation intact to touch, pain, and vibration. Cannot perform Romberg for balance or assess gait due to knee and shoulder
surgeries. Stereognosis, graphesthia, and proprioception intact. Deep tendon reflexes +2 in triceps, biceps, brachioradial,
patellar, and Achilles. Deep tendon reflexes not tested in left arm or right leg due to surgeries. Patient has negative Babinski.

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Lab
Dates
Trend
Analysis
WBC

Upon admit, the patients

Number of infection

University of South Florida College of Nursing Revision September 2014

12

19.5 H
21.8 H
26.6 H
21.0 H
18.7 H
Normal (4.5-10 thousand cells/mcL)

06/17/15
06/18/15
06/19/15
06/20/15
06/21/15

RBC
3.53 L
3.48 L
3.85 L
3.39 L
3.29 L
Normal (4.2-5.4 million cells/mcL)
Hgb
10.3 L
10.1 L
11.2 L
9.7 L
9.6 L
Normal (12 to 15.5 grams/dL

06/17/15
06/18/15
06/19/15
06/20/15
06/21/15
06/17/15
06/18/15
06/19/15
06/20/15
06/21/15

Hct
31.3 L
31.3 L
34.7 L
30.4 L
29.3 L
Normal (34.9 to 44.5%)
MCV
88.6
89.8
90.2
89.5
88.9
Normal (80-100 fL)

06/17/15
06/18/15
06/19/15
06/20/15
06/21/15
06/17/15
06/18/15
06/19/15
06/20/15
06/21/15

MCH
29.2
29.1
29.1
28.4

06/17/15
06/18/15
06/19/15
06/20/15

WBC were in the high

range. However, WBC
trended up and peaked at
26.6 and are currently
trending down indicating
either an infection or
inflammatory process is still
occurring but decreasing.

RBC indicates a decrease

overall. The labs trended up
and then dropped back
down, indicating blood loss.

Hemoglobin count is
trending down. This could
be due to bleeding but blood
loss is to be expected after
surgery.

Hematocrit is trending
down as well. This can also
be due to blood loss causing
the results to be misleading.

Mean corpuscular volume is

within normal range.

The mean corpuscular

hemoglobin is within
normal range.

fighting cells. High WBC

indicates the presence of an
infection or inflammation.
High WBC is often normal
after surgeries or trauma.
There is a risk for infection
and possibly consult
provider about antibiotics.
Need to watch each incision
site to look for oozing,
purulent drainage or
possible infection. Patient
still has foley in so check
for possible UTI.
Surgery can explain the
blood loss and the patients
body hasnt had time to
produce more RBC.

Surgery explains the low

hemoglobin. Transfusions
dont usually happen until
the hemoglobin is under 7.
The hemoglobin levels
should continue to be
monitored and the incision
sites and dressings should
be checked for bleeding.
Hematocrit can be
explained through blood
loss from the surgeries and
recovery period. It should
continue to be monitored
with the RBC and
hemoglobin.
Mean corpuscular volume is
the average volume of
RBCs in a specimen. This
determines the size of the
RBC and the ability to carry
a certain amount of
hemoglobin per red blood
cell. The patients MCV is
within normal range
meaning she has an average
RBC size.
The mean corpuscular
hemoglobin is the average
hemoglobin concentration
per red blood cell. Used
commonly to test and

University of South Florida College of Nursing Revision September 2014

13

29.1
Normal (27-33 (pg)/cell)
MCHC
32.9
32.4
32.3
32.8
32.7
Normal (32-36 g/dL)

06/21/15
06/17/15
06/18/15
06/19/15
06/20/15
06/21/15

Platelet Count
195
210
322
272
274
Normal (150-450 thousand
platelets/mcL)
Sodium
138
137
139
139
139
139
Normal (135-145 mEq/L)
Potassium
3.5
4.0
3.5
3.1 L
3.5
3.2 L
Normal (3.5-5.0 mEq/L)

06/17/15
06/18/15
06/19/15
06/20/15
06/21/15

06/17/15
06/19/15
06/20/15
06/21/15
06/22/15
06/23/15
06/17/15
06/19/15
06/20/15
06/21/15
06/22/15
06/23/15

Glucose
177 H
145 H
127 H
126 H
133 H
79 L
Normal (<100 mg/dL after fasting 8
hours, <140 mg/dL 2 hours after
eating)
BUN
9
9

06/17/15
06/19/15
06/20/15
06/21/15
06/22/15
06/23/15

06/17/15
06/19/15

evaluate anemia.
The mean corpuscular
hemoglobin concentration is
within normal limits.

Platelet count is within

normal range and stable.

The mean corpuscular

hemoglobin concentration is
the average concentration of
hemoglobin in a volume of
packed red blood cell or the
ratio of hemoglobin mass to
the volume of red blood
cells. MCHC is the most
commonly used test and to
evaluate anemia.
Platelets help the blood to
clot. Patient has normal
platelet range so they are
not at risk for bleeding or a
clot.

Sodium levels are within

normal range.

Sodium should be
monitored to check
electrolyte imbalances after
surgery. The patients
sodium levels are within
normal range but should
still be monitored.

The potassium levels began

at a normal range and
dropped to 3.1 but bounced
back up to 3.5 and then
back to 3.2 which is low.

Potassium is an important
electrolyte to have within
normal range because it can
lead to cardiac problems
like arrhythmias. The
potassium is trending down
so possibly consult the
provider about potassium
supplement. Low
potassium could be due to
patient having diarrhea
during the night.
Patient has diabetes mellitus
type 2 and takes insulin to
regulate glucose levels. The
difference in range could be
due to the patient not eating
a meal and the long-acting
insulin still being in her
system.

Patient has high glucose

level trending down. On
the 23rd, patients glucose
drops from 133 to 79.

Patients BUN level is

within normal range. Its a
little on the lower end of the

BUN is the blood urea

nitrogen level. This helps
determine whether the

University of South Florida College of Nursing Revision September 2014

14

11
9
8
8
Normal (7-20 mg/dL)

06/20/15
06/21/15
06/22/15
06/23/15

Creatinine
0.4 L
0.6
0.6
0.5 L
0.5 L
0.5 L
Normal (0.6 to 1.1 mg/dL)

06/17/15
06/19/15
06/20/15
06/21/15
06/22/15
06/23/15

Calcium
8.4 L
8.5 L
8.7 L
8.6 L
Normal (8.9-10.1 mg/dL)

06/20/15
06/21/15
06/22/15
06/23/15

Prealbumin
13.3 L

06/21/15

scale but it is still in range.

The creatinine levels are on

the lower end but not so low
where there should be
concern. They should
continue to be monitored.

Patient calcium levels are

on the low side. They are
higher on the 23rd than the
20th. It could be a sign of
kidney failure or just a
decrease in electrolyte
balance since the surgeries.

Use to determine nutritional

value. The patients
prealbumin is low probably
due to insufficient dietary
needs.

kidneys are functioning

properly. This is important
after a surgery due to
preventing organ failure and
shock. Since the levels are
on the low end, they should
continue to be monitored.
Creatinine levels determine
kidney function similarly to
BUN levels. Since the
creatinine levels are low,
they should continue to be
monitored to make sure they
dont continue to fall. If
they do continue to fall,
then possible kidney failure
could be occurring.
Half of the calcium in the
blood I attached to proteins
like albumin. Every cell
needs calcium in order to
work, muscles need it to
contract, the heart needs it
to function, and the nerves
use calcium for signaling,
and blood clotting. Possibly
increase calcium
supplement or absorption in
diet through food.
Prealbumin is made in the
liver and the body uses it as
building blocks to make
other proteins. It can be
evaluated to determine
nutritional insufficiency.
The patient probably needs
to eat more nutritional value
foods.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

Patient is on a 2000 ADA diabetic diet and gets her accuchecks done before each meal to determine the amount of
insulin coverage necessary (if any is necessary). Patients vitals are taken every 4 hours if the patient is not at
therapy. Patient has scheduled occupational therapy and physical therapy for 3 hours a day during the weekdays to
learn how to do ADLs and how to walk again after her surgeries.
8 NURSING DIAGNOSES
1. Impaired physical mobility r/t musculoskeletal impairment aeb weakness and pain in the right leg.
2. Ineffective peripheral tissue perfusion r/t surgery postoperative care aeb edema and weak peripheral pulses in the
right leg

University of South Florida College of Nursing Revision September 2014

15

University of South Florida College of Nursing Revision September 2014

16

 15 CARE PLAN
Nursing Diagnosis: Impaired physical mobility r/t surgery aeb weakness and pain in the right leg.
Patient Goals/Outcomes

Nursing Interventions to Achieve Goal

Patient will increase pedometer step

counts by 1000 steps per day every week
to reach a daily step count of at least 5000
steps per day

1.
2.

3.

Patient will demonstrate use of adaptive

equipment (i.e. wheelchairs and gait belts)
to increase mobility

1.
2.
3.

Patient will perform strength resistance

exercises that involve the lower
extremities during rehabilitation stay

1.

2.
3.

Use gait-walking belt when

ambulating the client
Allow for periods of rest before
planned exertion periods
(physical activity, meals, baths,
treatments)
Pain medication will be given
prior to activities.

Assist patient into wheelchair

throughout the day to move
around on their own.
Obtain any assistive devices
needed for activity.
Increase independent ADLs,
encouraging self-efficacy and
discouraging helplessness as
client gets stronger.
Refer patient to physical therapy
for resistance exercise training,
involving leg press, leg
extensions, leg curls, and calf
press.
Use gestures and nonverbal cues
when helping patients move.
Pain medications will be given
prior to activities and exercises.

Rationale for Interventions

Provide References
1. Gait-belts allow for patient to
walk independently while still
allowing the nurse/caregiver to
ensure safety should something
happen.
2. Physical rest allows for decrease
in pain levels to recuperate for
the next activity.
3. Reduces pain and allows for
longer durations during
movement and activities.
1. Improves functional performance
and independence.
2. Assistive devices can help
increase mobility
3. Providing unnecessary assistance
with activities may promote
dependence and loss of mobility.
1.

2.

3.
Patient will verbalize feeling of increased
strength and ability to move

1.

Help client to achieve mobility

and start walking as soon as
possible.

1.

Progressive resistance training

for physical disability in older
adults resulted in increased
strength and positive
improvements in some
limitations.
Nonverbal gestures are part of a
universal language that can be
understood when patient is
having difficulty with
communication.
Help patient reduce pain caused
by exercises and activities to
strengthen extremity.
Early mobilization promotes
improved function, reduces pain,
and facilitates earlier return to

University of South Florida College of Nursing Revision September 2014

Evaluation of Goal on Day Care is

Provided
1. The gait-belt was used to walk
the patient up and down hallway.
2. Patient had at least an hour to rest
before and after activities.
3. Patient was able to increase
amount of steps after pain
medicine was administered.

1.
2.
3.

1.
2.
3.

1.

Patient was able to use

wheelchair on their own.
Patient used wheelchair to move
around the room.
Patient bathed themselves and
needed minor assistance in
getting dressed.
Patient goes to physical therapy
twice a day for an hour each.
Patient got dressed with
nonverbal cues.
Patient performed strength
resistance exercises in physical
therapy.

The patient has been out of bed

with assistance to and from the
bedside commode and out of bed

2.

3.
Patient will increase physical activity to
60 minutes a day during rehabilitation
stay

1.

2.

3.

Before activity, observe for and,

if possible, treat pain with
massage, heat pack to affected
area, or medication.
Monitor and record the clients
ability to tolerate activity and use
all extremities.
If the client is immobile, perform
passive ROM exercises at least
twice a day unless
contraindicated; repeat each
maneuver three times.
Screen for mobility skills in the
following order: bed mobility,
supported and unsupported
sitting, transition movements (sit
to stand, sitting down, and
transfers), standing and walking
activities.
Watch for orthostatic hypotension
when mobilizing elderly patients.
Have patient dangle at side of
bed with legs hanging over the
edge of bed, flex and extend feet
several times after sitting up, then
stand up slowly with someone
holding the patient. If patient
becomes lightheaded or dizzy,
return them to bed immediately.

2.
3.

1.

2.

3.

independence.
Pain limits mobility and is often
exacerbated by movement.
Assessment of patients
achievements.
Physical rehabilitation
interventions were found to be
safe, reduced disability and
resulted in few adverse events.
Assess for quality of movement,
ability to walk and move, gait
pattern, ADL function, presence
of spasticity, activity tolerance,
and activity order.
Postural hypotension is very
common in the elderly

2.
3.

1.
2.
3.

for each meal.

Patient had no pain prior to
movement to wheelchair.
Observed patient doing ADLs
and recorded tolerance.
Patient performed passive ROM
twice a day with physical
therapy.
Patients mobility skills were
discussed and assessed prior to
physical activity.
Patient was observed while
getting out of bed prior to
physical activity and reported no
signs of dizziness.

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
X PT/ OT
Pastoral Care
Durable Medical Needs
X F/U appointments
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? X Yes No
X Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014

Reference
Ackley, B.J. & Ladwig, G.B. (2014). Nursing Diagnosis Handbook. (10th ed.). St. Louis, MO.: Mosby Elsevier.
Huether, S., & McCance, K. (2012). Understanding pathophysiology (5th ed.). St. Louis, Mo.: Mosby/Elsevier.

University of South Florida College of Nursing Revision September 2014